NP-led clinics Ontario leads the way

It’s been three years since Canada’s first NP-led clinic opened in Sudbury. What started as a local solution has since spread across the province, ushering in a new era in nursing leadership.

When Marilyn Butcher and Roberta Heale applied to the Ministry of Health and Long-Term Care in 2006 for an NP-led clinic in Sudbury, Ont., they knew it was a long shot. The proposal was their third attempt to obtain funding under the ministry’s Family Health Team (FHT) initiative. FHTs are based on a physician-led collaborative model of primary care, so when their proposal was rejected, the two NPs weren’t too surprised. But they also weren’t willing to take no for an answer.

Butcher and Heale knew that Sudbury had a chronic lack of family physicians and a resulting 30,000 “orphan” patients. They also knew other NPs in the area who were unemployed, working as RNs or considering moving as far as the U.S. to be able to practise in their field. “It was time for the government to make use of the available health human resources and use nurse practitioners to the full scope of their practice,” explains Butcher. “It made perfect sense for Sudbury.”

In July 2006, Butcher, who describes herself as “a bit of a political animal,” wrote a letter to Ontario’s minister of health, George Smitherman, to explain the rationale behind their proposal. She copied a long list of people, including the opposition health critics, members of provincial parliament and the Registered Nurses’ Association of Ontario. “Basically, I copied that letter to the world,” Butcher laughs.

It was a good strategy. The letter landed on the desk of RNAO’s executive director, Doris Grinspun, who was surprised to hear that there were unemployed NPs and quickly got on board. An intense period of lobbying and negotiating followed, and by November 2006 the ministry had announced the creation of an NP-led primary health care clinic in Sudbury, one that included everything Butcher and Heale had proposed.

“It seemed surreal,” Butcher says. “I felt like I had to pinch myself to believe this was actually happening. Roberta and I had set up practices before, but always for either a physician or an organization. Now we could do it for nurse practitioners. And we knew that if we did it properly, it could set the stage for nursing in the province, and perhaps across the country.”

NPs were already working in clinics and in other diverse roles in the province, but now they would be the clinic leaders. “The care that patients receive at an NP-led clinic is essentially no different from the care at a number of other clinics in the province where NPs provide the majority of care,” explains Heale, who served as the clinic’s first board president. “The difference is in the leadership and governance — it is delivered with an NP focus and voice.” The clinic has a community-based board of directors, half of whom are NPs. This structure ensures that any potential barriers to practice are addressed so that NPs can work to their full scope. The clinic director is also an NP, which means that a health-care professional, not an administrator, is in charge of setting the day-to-day operational goals.

Butcher, who was the clinic’s first director, gives an example of how that has made a difference: “Last year, when H1N1 first hit, I found out about it on a Friday night. By Monday morning, I had contacted our suppliers to get the N95 masks, had started pulling the policies and procedures that were going to be needed and had held a staff meeting to outline our plans to deal with the virus. An administrative lead wouldn’t have had the knowledge of what steps to take.”

The NP as clinic director concept provoked some controversy, particularly among the organized medical community. Representatives from the Ontario Medical Association and other groups were quoted in the media, questioning the safety and quality of care that patients would receive, implying that the NPs would be working independently. Butcher describes this response as a negative PR campaign. “First they said it was a ‘nurse-only clinic,’ which was clearly not true. Then they said that because it was an NP-led clinic, the nurse practitioners would be telling the physicians what to do.” She laughs. “I’m sure physicians would not be working in our clinic for very long if I were telling them what to do.”

Heale and Butcher emphasize that the NPs work collaboratively with physicians and other professionals. They note that many individual doctors were supportive, and the NPs had no problem recruiting physicians to work with them. The clinic also had the backing of the community — some residents went so far as to write letters to the editors of local and national newspapers to express their support.

While these controversies were playing out in the media, funding was starting to flow from the ministry, and the business of setting up the clinic began in earnest. The proposal called for six NPs, two collaborative physicians, four medical secretaries, a business manager, a half-time pharmacist, a registered nurse, a social worker and a dietitian to work in two locations — one in downtown Sudbury and one in the nearby community of Lively. Because the ministry released the funding in stages, not all positions could be staffed right away. The focus was on getting the downtown location up and running first. It officially opened in August 2007.

Clinic visitors might be surprised to see a hula hoop hanging on the wall. The hoop, which frames a poster of the clinic’s vision, mission and values statement, harkens back to a notorious comment made by Ontario Premier Mike Harris. After his government laid off several hundred nurses and other health-care workers in the late 1990s, Harris compared them to employees in hula hoop factories, whose jobs became obsolete after the fad died down in the 1960s. His comments enraged and galvanized Ontario’s nurses. For Butcher, the hula hoop became a symbol of the power of nursing leadership. Whenever politicians visit, she makes sure they see the red plastic ring and hear the story of why it’s there. “Politicians need to know that nurses are political activists,” she says.

A few weeks before the opening, a senior ministry official visited the site and asked Butcher about the advertising plan. She replied that she was more concerned about the phone lines being overloaded with calls — and believed that the considerable media attention the clinic had already received was promotion enough. She was right. On opening day, a small ad in the local paper announced that the clinic would open at 10 a.m. At 7 a.m., Butcher arrived to find a lineup stretching down the street: “It was a sea of white hair — people with walkers, people in wheelchairs, people with chronic diseases.” She adds, “I had mixed emotions. I was really glad the clinic was finally opening so we could begin providing care for these people. But part of me was so angry that they didn’t have care in the first place.” Butcher estimates that by opening time, between 300 and 400 people were waiting to get in, and she recalls sending her ministry contact an e-mail that read: “You really don’t need to worry about us not being busy enough. People are lined up out the door.”

Courtesy of Sudbury District Nurse Practitioner Clinics

From the first day, the clinic has had no problem attracting patients. The only requirement for registration is that people are not attached to any other primary health care provider; no one is turned away because of the complexity of their condition. New patients meet with an NP for a 45-minute interview that includes a full history-taking and ordering of any necessary tests. This is followed by an appointment for a review of test results and a full physical. “Often,” Heale explains, “they will say, ‘I haven’t received any care for a number of years, but I’m very healthy.’ Then it turns out they have two or three conditions needing treatment. We make sure new patients are stabilized before taking on any more. It’s a fairly intense process, but one that ensures that the NPs aren’t overloaded and can provide comprehensive and exemplary care.”

The wait time for new patients can range from a few weeks to a few months. The downtown location has reached its maximum of approximately 800 patients for each full-time NP and is not currently taking new patients. The new location in Lively, which opened this summer, is still accepting patients. (The NPs are also providing services to residents of the remote community of Chapleau several times per year.)

In addition to providing the full range of primary health care services, the clinic also runs weight management support, diabetes education and smoking cessation programs. Nina Hoyt, an NP who has been working at the downtown location since it opened, became clinic director when Butcher retired. She says that they are looking closely at their wellness programs to determine whether they can be offered to the community at large, perhaps in cooperation with other health-care providers in the area.

The immediate success of the clinic had a ripple effect far beyond what Heale and Butcher could have imagined. In November 2007, the government announced that it would open 25 more NP-led clinics around the province by 2012. “We were shocked,” Heale says. “Never in my life would I have thought that within three or four years of opening our clinic there would be 25 more.” But she emphasizes that NP-led clinics are not meant to take over from physicians or FHTs. “They were never meant to replace other models. They are simply a way to use the available health-care resources to the best advantage for community members.”

An evaluation conducted last year by the ministry, based on interviews, focus groups and more than 600 responses to a patient feedback survey, illustrated just how successful the Sudbury clinic has been. The report, Evaluation of the Sudbury District Nurse Practitioner Clinics (PRA Research and Consulting), showed impressive results in all categories the authors looked at, including awareness and understanding, physician integration and patient satisfaction. In addition to noting that “the NPs, doctors and other stakeholders who were interviewed generally showed a high level of satisfaction with the clinic” (p. 5), the authors reported:

Patients showed an overwhelmingly high level of satisfaction with the services they receive from their NP. The main reasons for high satisfaction were the attitudes of the NPs and the thoroughness of care provided. When compared with their previous health care situations, patients’ wait times have decreased. In addition, patients are pleased with the health education they receive from their NP. Since the clinic opened in Sudbury, the clinic’s patients believe that their access to health care has improved. (p. 3)

Butcher, who now sits on the clinic’s board, believes that this success story is one that other jurisdictions could learn from. She recalls presenting the clinic model at a nursing conference in Saskatchewan. When she finished speaking, the audience was silent — she thought they must not have liked what she was saying. Then someone yelled out, “My god, you’ve got us crying here.”

“You know,” she goes on to say, “you don’t have to be a political somebody to do this. Our clinic came out of a time when there were a lot of unemployed nurse practitioners, and there didn’t seem to be a lot of hope out there. But our experience showed that even when the chips are down, if you work hard at it and you’re with a group of people all working toward the same goal, you can get there.”